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MONITORING WELL INSTALLATION REPORT <br /> / CONSTRUCTION <br /> Date: <br /> Total Depth o ., <br /> Premise Address: Screen Length (from) (to) <br /> �? Filter Pack (from) (to) <br /> Well No.: <br /> Bentonite (from) (to) <br /> Inspector. << Grout (from) (to) <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> PermitNo. Completion - Stove pipe/christie box (cLrcle one) <br /> Drilling Company: <br /> casing <br /> Driller• �'�'�' height <br /> Consultant <br /> Geologist °�" ABO E-GROUND ��:sT�'�X <br /> C COYFLMON CIV�?LE1ION <br /> C-CCQnd Su1241 <br /> SPECIAL PERMIT INFO. <br /> grout <br /> Distance to sewer line <br /> Domestic well on site .- (y/ n) <br /> If yes, location and distance - ft' <br /> ~ O <br /> SAMPLING <br /> Holding Temperature <br /> Method <br /> Screening Method = <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contaminadon Noted - (y/ n) Casing type — <br /> Storage Location Blank ft. Screen h' <br /> Slot size <br /> Bags cement <br /> GROUPING Buckets bentonite ---- <br /> • Bags sand/gravel —� <br /> Depth to tvater Filter Pack type/size <br /> Miz Ratios Surge Block: - (y/n) <br /> 4pstallation Method Discussed vrith geologist: - (y/n) <br /> Quantity installed Type of method <br /> EH 29 29. <br />